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<br />WHEN THIS "COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />8/29/2017
<br />LINCOLN, NEBRASKA
<br />202000824
<br />ate
<br />STANLEY S. ()OPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Kenneth Paul Torpin
<br />4- cry AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Oakdale, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />94
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 19, 2017
<br />6. DATE OF BIRTH (Mo. 'Day, Yr.)
<br />May 13, 1923
<br />7. SOCIAL SECURITY NUMBER
<br />506-18-5806
<br />Sb. FACILITY -NAME (It not institution, give street and number)
<br />#9 Sonya Drive
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />0 Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Doniphan 68832.
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET ANO NUMBEit
<br />#9 Sonya Drive
<br />9b. COUNTY
<br />Hall
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Doniphan
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ® NO
<br />10a. MARITAL STATUS AT TIME OF DEATH O Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Alice Maude Foulk
<br />by: CERTIFIER.
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle,
<br />Henry Keith Torpin Vera Stanley
<br />Maiden Surname)
<br />13: EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yoe, No or Urnk.) Yes 11/06/1942-12/26/1945
<br />14a. INFORMANT -NAME
<br />Alice Maude Torpin
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other(Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central City Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />Central City
<br />CAUSE OF DEATH (See instructions and examples)
<br />1d PART I. Ender the Chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etio!ogy. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines H necessary.
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death) ..
<br />Sequentially Het condltlona,1f
<br />any, tending tothe danse Ilsted.
<br />Enter the UNDERLYING CAUSE
<br />(d merry et' Injuryaka initiated s>
<br />the events retuning; in death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a) Undetermined Natural Causes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />16c. DATE (Mo., Day, Yr.)
<br />August 24, 2017
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />O YES ❑ NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within pest year
<br />0 Pregnant at time of death
<br />0 Nat gra Cant, but pregnant within 42 days a deem
<br />0 Not pregnant, but pregnant 03 days to 1 year before death
<br />❑ tkarmiwn d Pregnant Within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑4 river/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />El Other(Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />it 5
<br />ih
<br />a O fid. To the best of my knowledge, death occurred at the time, date and place
<br />f, g and due to the cause(s) stated. (Signature and Title)
<br />r° f
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />25. Dip TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY I UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />August 22, 2017
<br />21P CODE
<br />24b. TIME OF DEATH
<br />Approx. 03:00 PM
<br />7.4c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />August 19, 2017
<br />24d. TIME PRONOUNCED DEAD
<br />03:00 PM
<br />244. On the basis of examination and/or investiga ion, in my opinion death oscurtad at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Tara Nagel, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR DONATION BEEN CONSIDERED?
<br />❑ YES i7 +
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ VES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Tara Nagel, Hall Deputy County Attorney, 231 S. Locust, P.O. Boy 367, Grand Island, Nebraska, 68802
<br />8a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 22, 2017
<br />1
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